SUBMISSION FOR AUTOMOBILE QUOTE
This form is for quote purposes and is non binding.
Please fill out this form COMPLETELY and submit.


Language Preferred 


Applicant's Name & Postal Address

Lessor (if applicable)

Name:  Name:
Address:
Address: 
Postal Code    Country  Postal Code   Country 
Phone: Work  Home  Phone:       Fax:   
E-Mail  E-Mail 














Described Automobile - Each automobile will be used primarily in the vicinity of the applicant's address, unless otherwise stated in Remarks.

Auto
No.

Model
year

Make or Trade Name

Model

Body Type

1.
2.
3.

 

 

 

 


 

Auto
No.

Vehicle Identification No.
(Serial No.)

Owned / leased

Pleasure
Use KM

Commute
One - Way
Use KM

Business
KM

Farm
KM

Commercial
KM

1.
2.
3.

Auto
No.

Estimated Annual
Driving Distance

1.
2.
3.








  • Is the applicant both the registered Owner and the Actual Owner of the desribed automobile(s)?
    If NO, give details:

  • Will any of the described automobiles be rented or leased to others, or used to carry passengers for compensation or hire, or haul a trailer, or carry explosives or radioactive material?
    If YES, give details:

  • Total number of automobiles in the household or business.

Driver Information - List all drivers of the described Automobile(s) in the household or business.

Driver
No.

Name as shown on
Driver's Licence

Driver's Licence
Number

Date of Birth
Year Month Day

Sex

Marital
Status

1.
2.
3.
4.






Are any other persons in the household or business licensed to drive? 
Driver
No.
Driver Training
certificate attached
Date First Licensed in Canada
  Class      Year        Month
Percentage Use by Each Driver
Auto 1        Auto 2      Auto 3
Is the principle driver of auto retired?

1.

2.

3.

4.


If a driver is licensed less than 6 years in Canada, driving in other countries may be recognized.
Please provide the details of the applicants most recent automobile insurance.
Insurance Company Policy No.
Expiry Date:  Year  Month  Day 

To the best of the applicant's knowledge.

  • Has any driver's licence, vehicle permit etc. issued to a person in the household or business been suspended or cancelled in the last 6 years?

  • If yes give details: 


  • Has any insurance company cancelled automobile insurance for the applicant or any listed driver in the last 3 years? 

  • If yes give details: 


  • During the last 3 years, has any automobile insurance policy issued to the applicant or any listed driver been cancelled or has any claim been denied for material misrepresentation? 

  • If yes give details: 


  • Has the applicant or any listed driver been found by a court to have committed a fraud connected with automobile insurance? 

  • If yes give details: 


Previous Accidents and Insurance Claims

Give details of all accidents or claims arising from the ownership, use or operation of any automobile by the applicant or any listed driver during the last 6 years.
#

Driver
No.

Auto
No.

Date
  Year     Month    Day  

Type of Claim

Amount Paid or Estimate

1.

2.

3.

4.








History of Convictions

Give Details of all convictions of the applicant and any listed driver arising from the operation of any automobile in the last 3 years.

Driver
No.

Date Convicted
 Year   Month   Day 

Details

Driver
No.

Date Convicted
 Year   Month   Day 

Details

Coverages Required (Mandatory)

Vehicle #

Liability

Accident Benefits

Property Deductible Damage

Uninsured Motorist

1.

2.
3.

Coverages Required  Loss or Damage (Optional)

Vehicle Collision Deductable Comprehensive Deductable Rental Car Collision Coverage Required
1.
2.
3.

Payment Option